Healthcare Provider Details

I. General information

NPI: 1003308149
Provider Name (Legal Business Name): PREMIER HEALTHCARE OF SHENANDOAH, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2018
Last Update Date: 08/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

813 CHURCH ST
SHENANDOAH IA
51601-2301
US

IV. Provider business mailing address

813 CHURCH ST
SHENANDOAH IA
51601-2301
US

V. Phone/Fax

Practice location:
  • Phone: 712-246-5954
  • Fax: 712-246-3269
Mailing address:
  • Phone: 712-246-5954
  • Fax: 712-246-3269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateIA

VIII. Authorized Official

Name: JEFFREY P MCCOY
Title or Position: PRESIDENT/OWNER
Credential: D.C.
Phone: 712-246-5954